An Internist’s Illustrated Guide to Gastrointestinal Surgery - part 1 pdf

AKBARI, MD • Assistant Professor of Surgery, Georgetown University School of Medicine, Attending Vascular Surgeon and Director, Vascular Diagnostic Laboratory, Washington Hospital Center

An Internist’s Illustrated Guide to Gastrointestinal

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AN INTERNIST’S ILLUSTRATED GUIDE TO GASTROINTESTINAL SURGERY

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CLINICAL GASTROENTEROLOGY

George Y Wu, MD, PhD, SERIES EDITOR

An Internist's Illustrated Guide to Gastrointestinal Surgery, edited by

George Y Wu, MD, P D, Khalid Aziz, MBBS, and Giles F Whalen, MD, 2003

Inflammatory Bowel Disease: Diagnosis and Therapeutics, edited by

Russell D Cohen, MD, 2003

Acute Gastrointestinal Bleeding: Diagnosis and Treatment, edited by Karen

E Kim, MD, 2003

Diseases of the Gastroesophageal Mucosa: The Acid-Related Disorders,

edited by James W Freston, MD, P D, 2001

Chronic Viral Hepatitis: Diagnosis and Therapeutics, edited by Raymond

S Koff, MD, and George Y Wu, MD, P D, 2001

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K HALID A ZIZ , MBBS , MRCP ( UK ), MRCP ( IRE ), FACG

G ILES F W HALEN , MD , FACS

University of Connecticut Health Center, Farmington, CT

999 Riverview Drive, Suite 208

Totowa, New Jersey 07512

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All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise without written permission from the Publisher.

Production Editor: Tracy Catanese.

Cover Illustration: From Figs 1 and 2 in Chapter 1, “Esophagectomy and Reconstruction” by Michael Kent, Jeffrey Port, and Nasser Altorki; Fig 3 in Chapter 11, “Surgery for Obesity” by Carlos Barba and Manuel Lorenzo; and Fig 4 in Chapter 25,

“Transjuglar Intrahepatic Portosystemic Shunt” by Grant J Price.

Cover design by Patricia F Cleary.

For additional copies, pricing for bulk purchases, and/or information about other Humana titles, contact Humana at the above address or at any of the following numbers: Tel: 973-256-1699; Fax: 973-256-8341; E-mail: humana@humanapr.com or visit our website at www.humanapress.com

Due diligence has been taken by the publishers, editors, and authors of this book to assure the accuracy of the information published and to describe generally accepted practices The contributors herein have carefully checked to ensure that the drug selections and dosages set forth in this text are accurate and in accord with the standards accepted at the time of publication Notwithstanding, as new research, changes in government regulations, and knowledge from clinical experience relating to drug therapy and drug reactions constantly occurs, the reader is advised to check the product information provided by the manufacturer of each drug for any change

in dosages or for additional warnings and contraindications This is of utmost importance when the recommended drug herein is a new or infrequently used drug It is the responsibility of the treating physician to determine dosages and treatment strategies for individual patients Further it is the responsibility of the health care provider to ascertain the Food and Drug Administration status of each drug or device used in their clinical practice The publisher, editors, and authors are not responsible for errors or omissions or for any consequences from the application of the information presented in this book and make no warranty, express or implied, with respect to the contents in this publication.

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Printed in the United States of America 10 9 8 7 6 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data

An internist's illustrated guide to gastrointestinal surgery / edited by George Y Wu [et al.].

p ; cm (Clinical gastroenterology)

Includes bibliographical references and index.

ISBN 1-58829-023-9 (alk paper); 1-59259-389-5 (e-book)

1 Gastrointestinal system Surgery I Wu, George Y., 1948- II Series.

[DNLM: 1 Digestive System Surgical Procedures methods WI 900 I598 2003]

D EDICATION

This book is dedicated to my students, whose questions prompted the writing, myfamily, whose patience permitted its creation, to Sigmund and Jenny Walder, whohave supported and encouraged us in all of our academic endeavors, and to Hermanand Frances Lopata and their family, whose generosity toward our research has madeavailable the time to devote to this book

G Y W.

To the memory of my parents, whose guidance has provided me with inspirationfor all of my accomplishments in life

K A.

To my teachers who have inspired me by their example, to my students who teach

me still by their questions and curiosity, to my patients whose lessons I have tried toabsorb, and to my family whose patience and tolerance of these endeavors make itall worthwhile

G F W.

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F OREWORD

Few clinical disciplines have been transformed so dramatically by advancements

in science and technology as gastrointestinal surgery To begin with, modern macology has virtually eliminated some kinds of surgery altogether If one were totake a peek at a typical operating room schedule in a busy hospital of the 1960s,gastrectomies of one kind or another would have constituted a large block of themajor surgeries The advent of effective H2-histamine receptor antagonists and, morerecently, the H+,K+-ATPase (proton pump) inhibitors led to a precipitous decline inthose procedures such that they are rarely performed today Exciting new approaches

phar-to treating inflammaphar-tory bowel diseases and their complications—such as fistulas—with anticytokine therapy may one day have a similarly profound effect on surgeryfor this condition as well

Beyond pharmaceutics, advances in imaging techniques have greatly facilitatedthe identification and characterization of pathology in the gastrointestinal tract in away that would have been unimaginable only a few years ago Just to visualize thepancreas in some way was a horrendous task until abdominal ultrasound, magneticresonance imaging, or computer tomography made it simple The fact that the gut is

a hollow organ that can be accessed through the mouth, anus, or even through thewall of the abdomen has been fully exploited with fiberoptic endoscopes that canbend around corners with ease and permit surgery to be conducted through them.Many physicians have earned their spurs in the operating room by laboriously hang-ing on to a Deaver retractor while a surgeon deftly removes a patient’s gallbladder.Today, of course, laparoscopic surgery has virtually eliminated open cholecystec-tomy and threatens to make other complex surgeries, such as fundoplication or colec-tomy, obsolete Other advanced technologies, such as transhepatic intravenousporta-systemic shunts, have practically converted dangerous and difficult operations

to relieve portal pressure in liver disease to an outpatient procedure

Despite these amazing advances, today’s surgeon may still be called on to form virtually all of the operations that have been performed for years, some evenfor centuries Gastrectomies, cholecystectomies, fundoplications, colectomies, andporta-caval shunts all have to be performed on patients The surgeon of today must

per-be equally adept at performing traditional abdominal surgery as well as surgerythrough scopes, percutaneous wires, and the like

The transformation that surgeons have had to make in the recent past has alsonecessitated change in the internist’s practice To begin with, the internist now hasmany options to choose from in treating patients with abdominal illnesses It isimportant for the internist to understand the advantages and limitations of the differ-ent therapeutic approaches that might be taken Thorough discussion and collabora-tion of an internist with the surgeon, both being well-informed on the approaches totherapy, will inevitably provide the best outcome for the patient Beyond initial

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therapy, the internist almost certainly sees patients who have undergone varioussurgical procedures It goes without saying that internists must be adept at handlingthe sequelae of surgery, some of which may have profound effects on normal physi-ological function.

An Internist’s Illustrated Guide to Gastrointestinal Surgery by Wu, Aziz, and Whalen

is directed at educating the internist on the common surgical approaches to tinal disorders It is carefully written in language that would have meaning to an inter-nist In a logical way, each topic is approached from the standpoints of pathophysiology,diagnostic evaluation, treatment, and sequelae Each chapter is accompanied by clearand simple diagrams that depict the essentials of the operation performed The bookcovers both the “old surgery” of gastrectomies, colectomies, and cholecystectomies,

gastrointes-as well gastrointes-as the “new surgery” of shunts, laparoscopic procedures, and TIPS It is meantnot only for the practicing internist but is equally appropriate for all students or othertrainees in medicine who are bound to see patients who undergo surgery for gastrointes-

tinal illness An Internist’s Illustrated Guide to Gastrointestinal Surgery should not

only provide the reader with an understanding of the science and practice of trointestinal surgery, but also equip the reader with the tools to be a better physician

gas-Tadataka Yamada, MD

Adjunct Professor Department of Internal Medicine University of Michigan Medical School Chairman, Research and Development

GlaxoSmithKline

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P REFACE

In general, primary care providers, family practitioners, and gastroenterologistshave a limited knowledge of abdominal surgical operations, the medical aspects ofthese surgical procedures, and their immediate and late complications In addition,these patients traditionally are not followed up by the surgeons, and thus the internistmust become familiar with postsurgical problems in order to provide appropriatelong-term care A clear understanding of the concepts that underlie the surgery iscrucial for proper management of these patients

In addition, within the last 10 years, laparoscopic surgery has become increasinglycommonplace, with new laparoscopic procedures being developed at a rapid pace.There are vast differences between traditional and laparoscopic surgery, not only inthe way these procedures are performed, but also in their outcomes and complications.Many internists, as well as surgeons, have very limited understanding of these proce-dures Therefore, the need exists for a book that can provide useful clinical informa-tion in an easy to access format, covering a variety of abdominal surgical procedures.Almost all surgical books provide great detail about the technical aspects of surgi-cal procedures and their surgical complications However, the physician who needs

to manage the patient who has undergone gastrointestinal (GI) surgery, currentlymust go through surgical texts to find the disease, and then the type of surgery thepatient has undergone, wading through pages of details about the surgical procedure,without dealing with the issues relevant to the medical management of the patient.Thus, it is currently difficult for the nonsurgically trained physician to extract the

relevant medical information An Internist’s Illustrated Guide to Gastrointestinal

Surgery is a comprehensive textbook describing all of the surgical and laparoscopic

procedures for the GI tract in a simple way, with artistic illustrations to educate thephysician about surgery of the GI tract, and to provide not only clear descriptions ofthe changes in the anatomy and physiology, but also advice on medical management

of the postsurgical patient

An Internist’s Illustrated Guide to Gastrointestinal Surgery describes in detail

the indications, contraindications, anatomical alterations, and physiological ations that result from various GI operations and procedures Comparison betweenalternative operations, complications, medical management issues, and costs of thesesurgical procedures and operations are discussed Clear, detailed, artist-renderedillustrations of the anatomy before and after surgery are included and, where appro-priate, radiological images before and after surgery

alter-This is a unique textbook, written primarily for primary care physicians, generalinternists, and gastroenterologists to educate them about those aspects of GI sur-gery—including laparoscopic surgery—that are pertinent to an internist It shouldalso be a suitable textbook for medical students, residents, nurses and nurse practi-tioners, nutritionists, dietitians, and various subspecialists, who often take care ofpostsurgical patients

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C ONTENTS

xi

Foreword vii Preface ix Contributors xiii

PART I ESOPHAGEAL SURGERY

1 Esophagectomy and Reconstruction 3

Michael Kent, Jeffrey Port, and Nasser Altorki

2 Zenker's Diverticulum 17

Anders Holm and Denis C Lafreniere

3 Esophagectomy for Achalasia:

Laparoscopic Heller Myotomy and Dor Fundoplication 23

Joshua M Braveman, Lev Khitin, and David M Brams

4 Surgery for Gastroesophageal Reflux Disease 33

Lev Khitin and David M Brams

5 Hiatal Hernia Repair 47

Lev Khitin and David M Brams

6 Esophageal Stents 57

Gaspar Nazareno, Nii Lamptey-Mills, and Jay Benson

7 Endoscopic Therapy for Esophageal Varices 65

Jaroslaw Cymorek and Khalid Aziz

PART II GASTRIC SURGERY

8 Surgical Treatment of Peptic Ulcer Disease 75

Brent W Miedema and Nitin Rangnekar

9 Surgical Management of Gastric Tumors 87

Robert C G Martin and Martin S Karpeh, Jr.

10 Reconstruction After Distal Gastrectomy 99

Nitin Rangnekar and Brent W Miedema

11 Surgery for Obesity 115

Carlos Barba and Manuel Lorenzo

12 Percutaneous Enterostomy Tubes 123

Gaspar Nazareno and George Y Wu

PART III SMALL BOWEL SURGERY

13 Small Bowel Resections 141

Eric M Knauer and Robert A Kozol

14 Urinary Diversion Surgery 151

Scott Rutchick and Peter Albertsen

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xii Contents

PART IV LARGE BOWEL SURGERY

15 Colonic Resection 163

Robert A Kozol

16 Surgery of the Rectum and Anus 175

Mark Maddox and David Walters

PART V HEPATIC AND BILIARY SURGERY

17 Hepatic Resection 195

John Taggert and Giles F Whalen

18 Bypass and Reconstruction of Bile Ducts 207

John Taggert and Giles F Whalen

19 Cholecystectomy 215

John Taggert and Giles F Whalen

PART VI PANCREATIC SURGERY

20 Pancreatic Surgery 227

Janette U Gaw and Dana K Andersen

21 Endoscopic Management of Pancreatic Pseudocysts 249

Gaspar Nazareno and Khalid Aziz

PART VII SURGERY ON AORTA AND ITS BRANCHES

22 Surgery of the Abdominal Aorta and Branches 261

Stephanie Saltzberg, Justin A Maykel, and Cameron M Akbari

23 Endovascular Repair of Abdominal Aortic Aneurysm 271

Grant J Price

PART VIII SURGERY ON PORTAL VEIN

24 Portasystemic Venous Shunt Surgery for Portal Hypertension 283

David K W Chew and Michael S Conte

25 Transjuglar Intrahepatic Portosystemic Shunt 297

Grant J Price

PART IX ABDOMINAL HERNIA SURGERY

26 Hernia Surgery 311

Christine Bartus and David Giles

PART X PERITONEAL SURGERY

C ONTRIBUTORS

xiii

CAMERON M AKBARI, MD • Assistant Professor of Surgery, Georgetown University School

of Medicine, Attending Vascular Surgeon and Director, Vascular Diagnostic Laboratory, Washington Hospital Center, Washington, DC

PETER ALBERTSEN, MD • Professor of Surgery, Chief, Division of Urology,

Department of Surgery, University of Connecticut, Farmington, CT

NASSER ALTORKI, MD • Professor of Thoracic Surgery, Department of Cardiothoracic Surgery, The New York Presbyterian Hospital, Weill-Cornell Medical Center, New York, NY

DANA K ANDERSEN, MD • Professor of Surgery, Department of Surgery, University of Massachusetts Memorial Medical Center, Worcester, MA

KHALID AZIZ, MBBS, MRCP (UK), MRCP (IRE), FACG • Assistant Professor of Medicine,

Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT

CARLOS BARBA, MD • Chief of Bariatric Surgery, Chief of Trauma, Associate Director

of Surgical Critical Care, St Francis Hospital and Medical Center, Hartford, CT

CHRISTINE BARTUS, MD • Surgical Resident, Department of Surgery, University of Connecticut Health Center, Farmington, CT

JAY BENSON, MD • Associate Professor of Medicine, Division of

Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT,

and Attending Physician, St Francis Hospital and Medical Center, Hartford, CT

DAVID M BRAMS, MD • Staff Surgeon, Department of General Surgery, Lahey Clinic Medical Center, Burlington, MA

JOSHUA M BRAVEMAN, MD • Chief Surgical Resident, Department of General Surgery, Lahey Clinic Medical Center, Burlington, MA

DAVID K W CHEW, MD • Instructor in Surgery, Division of Vascular Surgery,

Brigham and Women's Hospital, Boston, MA

MICHAEL S CONTE, MD • Associate Professor of Surgery, Division of Vascular Surgery, Brigham and Women's Hospital, Boston, MA

JAROSLAW CYMOREK, MD • Senior GI Fellow, Division of Gastroenterology-Hepatology, University of Connecticut Health Center, Farmington, CT

LILY H FIDUCCIA • Freelance Illustrator

JANETTE U GAW, MD • Surgical Resident, Department of Surgery, Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT

DAVID GILES, MD • Assistant Professor, Department of Surgery, University of Connecticut Health Center, Farmington, CT

ANDERS HOLM, MD • Chief Surgical Resident, Department of Otolaryngology,

University of Connecticut Health Center, Farmington, CT

MARTIN S KARPEH, JR., MD • Chief of Surgical Oncology, Department of Surgery,

State University of New York at Stony Brook, Stony Brook, NY

MICHAEL KENT, MD • Assistant Professor of Surgery, Department of Cardiothoracic Surgery, The New York Presbyterian Hospital, Weill-Cornell Medical Center, New York, NYThis is trial version

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xiv Contributors

LEV KHITIN, MD • Resident Surgeon, Department of General Surgery, Lahey Clinic Medical Center, Burlington, MA

ERIC M KNAUER, MD • Chief Surgical Resident, Department of Surgery,

University of Connecticut School of Medicine, Farmington, CT

ROBERT A KOZOL, MD, MHA, FACS • Professor of Surgery, Chief Division of Surgery, University of Connecticut Health Center, Farmington, CT

DENIS C LAFRENIERE, MD, FACS • Associate Professor of Surgery, Department of Otolaryngology, University of Connecticut Health Center, Farmington, CT

NII LAMPTEY-MILLS, MD • GI Fellow, Department of Medicine, Division of Hepatology, University of Connecticut Health Center, Farmington, CT

Gastroenterology-MANUEL LORENZO, MD • Associate Director of Surgical Critical Care and Trauma,

and Director Medical Clinics, St Francis Hospital and Medical Center, Hartford, CT

MARK MADDOX, MD • Fellow, Colon and Rectal Surgery, St Francis Hospital and Medical Center, Hartford, CT

ROBERT C G MARTIN, MD • Chief Surgical Fellow, Department of Surgery, Cornell Medical College, Memorial Sloan Kettering Cancer Center, New York, NY

JUSTIN A MAYKEL, MD • Surgical Resident, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA

BRENT W MIEDEMA, MD • Associate Professor, Department of Surgery, University of Missouri Medical Center and Harry S Truman Veterans Administration Hospital, Columbia, MO

GASPAR NAZARENO, MD • GI Fellow, Department of Medicine, Division of Hepatology, University of Connecticut Health Center, Farmington, CT

Gastroenterology-JEFFREY PORT, MD • Assistant Professor of Surgery, Department of Cardiothoracic Surgery, The New York Presbyterian Hospital, Weill-Cornell Medical Center, New York, NY

GRANT J PRICE, MD, MSCVIR, MACR • Chairman of Radiology, Somerset Medical Center, Somerville, NJ

NITIN RANGNEKAR, MD • Assistant Professor, Department of Surgery, University of Missouri Medical Center and Harry S Truman Veterans Administration Hospital, Columbia, MO

SCOTT RUTCHICK, MD • Assistant Professor, Department of Surgery, Section of Urology, University of Connecticut, Farmington, CT

STEPHANIE SALTZBERG, MD • Chief Resident, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA

JOHN TAGGERT, MD • Surgical Resident, Department of Surgery, University of Connecticut School of Medicine, Farmington, CT

DAVID WALTERS, MD • Assistant Professor of Colorectal Surgery, University of Connecticut Health Center, Farmington, CT

GILES F WHALEN, MD, FACS • Professor of Surgery, Department of Surgery,

University of Connecticut Health Center, Farmington, CT

GEORGE Y WU, MD, P h D • Professor of Medicine, Chief, Division of Hepatology, Herman Lopata Chair in Hepatitis Research, University of Connecticut Health Center, Farmington, CT

Gastroenterology-This is trial version www.adultpdf.com

Chapter 1 / Esophagectomy and Reconstruction 1

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2 Kent, Port, and Altorki

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Chapter 1 / Esophagectomy and Reconstruction 3

3

From: Clinical Gastroenterology: An Internist's Illustrated Guide to Gastrointestinal Surgery

Edited by: George Y Wu, Khalid Aziz, and Giles F Whalen © Humana Press Inc., Totowa, NJ

INTRODUCTION

Esophagectomy is one of the most formidable operations performed by the trointestinal (GI) surgeon Esophageal resection carries a complication rate of more than40%, and should only be performed in centers experienced with the management of thesepatients Indeed, the mortality of esophagectomy has been shown to be significantly

gas-lower in larger volume centers (1).

Esophageal resection is most frequently performed for carcinoma of the esophagus.Although less common, several other benign conditions may necessitate esophagectomy.For example, severe caustic burns to the esophagus often require esophageal resectionand reconstruction Esophageal perforation, primary motility disorders such as achalasiaand scleroderma, and unsuccessful antireflux operations are additional indications foresophagectomy Usually, these diseases may be managed with esophageal-sparing sur-gery, such as fundoplication or myotomy Esophagectomy often represents the finaltreatment of patients with a variety of benign conditions who have failed more conser-vative surgical management

1 Esophagectomy and Reconstruction

Michael Kent, MD , Jeffrey Port, MD , and Nasser Altorki, MD